More damning evidence is out on the callousness of the Bush administration towards its own soldiers returning from battlefields of Iraq and Afghanistan.
The veterans are finding it evermore difficult to get mental health treatment because military insurance is cutting payments to therapists, on top of the already low reimbursement rates and a tangle of red tape, reports say. Tricare, the military health insurance program, is virtually in a shambles.
Wait lists now extend for months to see a military doctor and it can takes weeks to find a private therapist willing to take on members of the military. The challenge appears great in rural areas, where many National Guard and Reserve troops and their families live.
To avoid the hassles of Tricare, one frustrated therapist opted to provide an hour of therapy time a week to Iraq and Afghanistan veterans for free. Barbara Romberg, a clinical psychologist in the Washington, D.C., area, has started a group that encourages other therapists to do the same.
"They're not going to pay me much in terms of my regular rate anyway," Romberg said. "So I'm actually feeling positive that I've given, rather than feeling frustrated for what I'm going through to get payment."
Joyce Lindsey, 46, of Troutdale, Ore., sought grief counseling after her husband died in Afghanistan last December. The therapist recommended by her physician would not take Tricare. Lindsey eventually found one on a provider list, but the process took two months.
"It was kind of frustrating," Lindsey said. "I thought, 'Am I ever going to find someone to take this?'"
Roughly one-third of returning soldiers seek out mental health counseling in their first year home. They are among the 9.1 million people covered by Tricare, a number that grew by more than 1 million since 2001.
Tricare's psychological health benefit is "hindered by fragmented rules and policies, inadequate oversight and insufficient reimbursement," the Defense Department's mental health task force said last month after reviewing the military's psychological care system.
The Tricare office that serves Fort Campbell, Ky., on the Tennessee-Kentucky state line, and Fort Bragg, N.C. — Army posts with heavy war deployments — told task force members that it routinely fields complaints about the difficulty in locating mental health specialists who accept Tricare.
"Unfortunately, in some of our communities ... we are maxed out on the available providers," said Lois Krysa, the office's quality manager. "In other areas, the providers just are not willing to sign up to take Tricare assignment, and that is a problem."
Tricare's reimbursement rate is tied to Medicare's, which pays less than civilian employer insurance. The rate for mental health care services fell by 6.4 percent this year as part of an adjustment in reimbursements to certain specialties.
Since 2004, Tricare has sped up payments to encourage more doctors to participate, said Austin Camacho, a Tricare spokesman. In some locations, such as Idaho and Alaska, the Defense Department has also raised rates to attract physicians, he said.
"We are working hard to overcome those challenges," Camacho said.
Jack Wagoner is a retired military officer and psychologist and psychiatrist in private practice who also works for a Tricare contractor. He told defense mental health board members last December that in general, Tricare pays "considerably lower" than private health insurance plans.
According to data from Tricare's Medical Benefits and Reimbursement System office, Tricare pays mental health providers as much or more than a corporate plan would pay a therapist for treating a patient — although in some cases it is lower.
There are different coverage plans within Tricare, and the amount paid to providers varies by plan, location, specialty and services performed.
Psychologists who treat active duty troops are paid 66 percent of what Tricare views as the customary rate. So a psychologist eligible for a customary rate of $120 per hour would be paid $79.20 for the hour by Tricare, even if the psychologist's standard rate is $150 per hour.
Active duty troops use Tricare Prime, a managed-care option maintained by private contractors. Their mental health care is free. Guard and Reserve troops and their families frequently use Tricare Standard, a fee-for-service plan. They pay an annual deductible and 20 percent of the amount Tricare pays the therapist.
John Class, a retired Navy health care administrator who now advocates on health issues for the Military Officers Association of America, said Tricare Prime contractors insist that the lower reimbursement rates has made it tougher to maintain a network of providers.
"We are already starting to see the pinch," Class said.
In a limited study by Tricare released earlier this year, about two out of three civilian psychiatrists in 20 states were willing to accept Tricare Standard clients among their new patients, the lowest acceptance rate for any specialty.
Any additional cuts in Tricare payouts could mean that "some really good psychologists who specialize in this treatment and are experienced will be seeing less of (military families)," said clinical psychologist Marion Frank, a widow who is president of the Philadelphia Chapter of the Gold Star Wives of America, a support group for military widows.
In parts of Montana, some families drive two hours to see a physician of any kind that will take Tricare, said Dorrie Hagan, state family program director for the Montana National Guard.
"When you get away from a city of any size then you start struggling for providers, and they'll tell you flat out it's because of the rate of pay," Hagan said.
Another commented bitterly, "I have watched my husband's life, (and quite a few others) go downhill rapidly, because of PTSD (post traumatic stress disorder). I've watched men, who were strong, healthy, productive people, become suspicious, hyper-vigilant, self-medicating, self-destructive, and worse, because of being sent by this government to places where they should not be, but have been conned by the government and the military into believing that they are "doing their duty!". I've dealt with the VA system for almost 30 yrs. now, and it just get more atrocious as time goes on."